What is the interventional treatment for iliac and femoropopliteal (fem-pop) Peripheral Vascular Disease (PVD)?

Interventional Treatment for Iliac and Femoropopliteal Peripheral Vascular Disease

Treatment Selection Based on Anatomic Location

For iliac artery disease, primary stenting of the common iliac artery and balloon angioplasty with provisional stenting for external iliac arteries should be your first-line approach, while for femoropopliteal disease, drug-eluting treatment (drug-eluting balloons or stents) is now the preferred endovascular strategy. 1

Iliac Artery Interventions

Primary stenting is effective and recommended for common iliac artery stenoses and occlusions as first-line therapy, achieving excellent long-term patency rates. 1

For external iliac arteries:

• Balloon angioplasty should be performed first, with stenting reserved for suboptimal results (persistent translesional gradient, residual stenosis >50%, or flow-limiting dissection). 1
• Primary stenting is also effective for external iliac stenoses and occlusions, though the evidence level is slightly lower than for common iliac disease. 1

Before intervening on iliac stenoses of 50-75% diameter, obtain translesional pressure gradients with and without vasodilation to confirm hemodynamic significance—do not treat lesions without a significant gradient. 1

Femoropopliteal Artery Interventions

Drug-eluting treatment (drug-eluting balloons or drug-eluting stents) should be considered as the first-choice strategy for femoropopliteal lesions, based on the most recent 2024 ESC guidelines. 1 This represents an evolution from older guidelines that were more cautious about stenting in this territory.

The FDA initially raised safety concerns about drug-eluting devices in femoropopliteal arteries but subsequently revised its position after large national databases failed to confirm mortality signals—drug-eluting treatment is now deemed safe and efficient for femoropopliteal lesions. 1

Endovascular therapy should be the first choice even for complex femoropopliteal lesions, particularly in surgical high-risk patients. 1

Primary stent placement is NOT recommended in the femoral, popliteal, or tibial arteries according to older ACC/AHA guidelines, though this has been superseded by evidence supporting drug-eluting devices. 1 The key distinction is that bare metal stents should be avoided as primary therapy, but drug-eluting devices are now preferred. 1

Surgical Revascularization: When to Consider

Open surgical approach should be considered when an autologous vein (great saphenous vein) is available AND the patient has low surgical risk, particularly for complex femoropopliteal lesions after interdisciplinary team discussion. 1, 2

Surgery is the treatment of choice for TASC type D lesions (complete common femoral artery or superficial femoral artery occlusions, or complete popliteal and proximal trifurcation occlusions). 1

For TASC type B and C lesions, the evidence remains mixed—endovascular therapy is increasingly used even for these complex lesions, though surgical options should be discussed in a multidisciplinary setting. 1

TASC Classification-Based Algorithm

TASC Type A lesions: Endovascular intervention is the clear treatment of choice. 1

• Iliac: Single stenosis of CIA or EIA
• Femoropopliteal: Single stenosis <3 cm

TASC Type B lesions: Endovascular approach is increasingly preferred, though evidence is not definitive. 1

• Iliac: Short stenoses (3-10 cm) or unilateral CIA occlusion
• Femoropopliteal: Single stenosis 3-10 cm, heavily calcified stenoses up to 3 cm, or multiple lesions each <3 cm

TASC Type C lesions: Either endovascular or surgical based on patient factors and local expertise. 1

• Iliac: Bilateral CIA or EIA stenoses, unilateral EIA occlusion
• Femoropopliteal: Single stenosis or occlusion >5 cm, multiple lesions 3-5 cm each

TASC Type D lesions: Surgery is preferred. 1

• Iliac: Diffuse disease, bilateral occlusions, iliac stenosis with AAA
• Femoropopliteal: Complete CFA/SFA occlusions or complete popliteal occlusions

Below-the-Knee Considerations

In patients with severe intermittent claudication undergoing femoropopliteal endovascular treatment, below-the-knee arteries may be treated in the same intervention if there is substantially impaired outflow. 1

Critical Caveats and Pitfalls

Do NOT perform endovascular intervention if there is no significant pressure gradient across a stenosis despite vasodilator administration—this is contraindicated. 1

Revascularization is NOT indicated solely to prevent progression to chronic limb-threatening ischemia—this approach lacks evidence and may be harmful. 1, 2

Do NOT perform revascularization in asymptomatic patients—intervention is contraindicated without symptoms. 1

Expect diminished long-term patency with: greater lesion length, occlusion rather than stenosis, multiple diffuse lesions, poor runoff, diabetes, chronic kidney disease, and smoking. 1, 2

Be aware that 20-30% of patients may have persistent symptoms despite patent stents, requiring careful patient selection and realistic expectations. 2, 3

For in-stent restenosis, balloon angioplasty alone has very high failure rates—consider repeat stenting for recurrent stenosis. 3

Patient Selection Requirements

Revascularization should only be considered after 3 months of optimal medical therapy and exercise therapy if quality of life remains impaired. 1

Optimal medical therapy includes: antithrombotic therapy (aspirin or clopidogrel, with consideration of rivaroxaban 2.5 mg twice daily plus aspirin for high-risk patients), statin therapy, blood pressure control, and smoking cessation. 1

Supervised exercise therapy should consist of at least 30 minutes, at least three times weekly for a minimum of 12 weeks before considering revascularization. 1